Wiki Wellcare Medicare claim denial for TCM code 99496 -- needs related or qualifying procedure code???

[she803]

Good afternoon--we received claim denial from Wellcare Medicare for CPT 99496 TCM requesting for related or qualifying procedure code.

On the site It indicates that "Deny Transitional Care Management (TCM) services (99495-99496) when billed and another TCM Service (99495-99496) has been billed on the same date of service by any provider"

CPT code 99496 was billed once on service date 05/19/2022. However, the patient was discharged from ER/ED one day prior on 05/18/2022. Are the service dates only a day apart a discrepancy resulting in claim denial?

Unfortunately, this insurance company only provided the above denial reason that a related code or qualifying code is needed.

Please advise--thanks in advance!!

 

[lgardner]

is it possible that another TCM was billed in the last 30 days?

 

[AmandaBriggs]

That was my question as well. Or possibly another provider other than yours billed within the last 30 days?

 

[she803]

That was my question as well. Or possibly another provider other than yours billed within the last 30 days?

 

[she803]

I checked patient's history--there were no other TCM's billed but that one.

 

[GottaLaugh]

It sounds to me that the insurance is looking for a discharge management CPT, in the patient's claim history.

TCM isn't billable when the patient is discharged from the emergency room. The patient has to be discharged from one of the following: Inpt Acute Care Hospital, LTC Hospital, SNF, Inpt Rehab Facility. They must be released to wherever they will be living: Home, Domiciliary Home, Rest Home or Assisted Living.

 

[lgardner]

It sounds to me that the insurance is looking for a discharge management CPT, in the patient's claim history.

TCM isn't billable when the patient is discharged from the emergency room. The patient has to be discharged from one of the following: Inpt Acute Care Hospital, LTC Hospital, SNF, Inpt Rehab Facility. They must be released to wherever they will be living: Home, Domiciliary Home, Rest Home or Assisted Living.

I, somehow, missed that the patient was discharged from the ED.
that, definitely does not qualify for a TCM.